Method and system for balloon counterpulsation during aortic valve replacement

ABSTRACT

Methods and systems for regulating aortic regurgitation during aortic valve replacement or repair procedures utilize a temporary aortic valve (TAV) catheter and a controller. The temporary aortic valve catheter has an expandable occlusion device which can partially occlude the aortic lumen during ventricular diastole with a lesser occlusion during ventricular systole. Exemplary balloon structures include multiple, independently inflatable balloons which are inflated in synchrony with the cardiac cycle by the controller. By controlling aortic regurgitation, the repair or replacement protocols can be conducted with less interference from blood flow.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.13/227,276, filed Sep. 7, 2011, which claims the benefit under 35 U.S.C.§119 of U.S. Provisional Patent Application No. 61/384,989, filed Sep.21, 2010, the full disclosures of which are incorporated herein byreference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to medical devices and methods.More particularly, the present invention relates to a method and systemfor facilitating percutaneous aortic valve replacement.

Patients suffering from significant aortic valve disease are frequentlytreated by aortic valve replacement procedures. While most aortic valvereplacements are still performed in open chest procedures, recentlythere have been significant advances in minimally invasive aortic valvereplacement where the valve is introduced through either a transapicalapproach (minimally invasive) or a transvascular (percutaneous) approachover the aortic arch.

Both transapical and transvascular PAV procedures are “beating heart”procedures where continuing blood flow from the left ventricle into theaorta creates hemodynamic forces on the replacement valves and the toolsused in the replacement procedures. In an effort to control thehemodynamic forces and to stabilize the tools and valve used forreplacement, that the use of a “temporary aortic valve” (TAV) hasrecently been proposed. As described in commonly owned published USPatent Applications US 2009/0030503 and US 2009/0030510, the fulldisclosures of which are incorporated herein by reference, a catheter isintravascularly introduced over the aortic arch to position a balloonassembly in the ascending aorta just above the Sinus of Valsalva. Theballoon assembly includes three equally sized balloons disposed inparallel about the distal tip of the catheter, and the inflated balloonstogether limit retrograde blood flow (flow in the direction from theaorta toward the aortic valve) during diastole, thus limitingdisturbance of the tools and/or valves located in the aortic valveannulus during the procedure. The balloon inflation only partiallyoccludes the aortic lumen in order to both allow antegrade flow duringsystole and to permit a limited retrograde flow during diastole in orderto perfuse the coronary vasculature through the Sinus of Valsalva and toprotect the left ventricle from excessive volume overload.

While of great potential benefit, the use of the balloon structuresdescribed in the prior patent applications is necessarily a compromisebetween resistance to regurgitation during diastole and forward bloodflow patency through the aorta during systole. Also, the balloonstructures and protocols described in the published patent applicationsdo not provide for adjusting the extent of occlusion of the aorta as maybe optimal during different stages of the valve removal and replacementprocedures.

For these reasons, it would be desirable to provide methods and systemsfor occluding the aorta to limit aortic regurgitation during valverepair and replacement procedures where the degree of aortic occlusioncan be adjusted during the procedure, both in synchronizing with thesystolic and diastolic portions of the heartbeat and during differentsegments of the procedure, such as valve ablation, valve removal,replacement valve positioning, replacement valve assembly, and the like.At least some of these objectives will be met by the inventionsdescribed herein below.

2. Description of the Background Art

US Patent Publications US 2009/0030503 and US 2009/0030510 have beendescribed above. The use of an intra-aortic balloon pump during coronaryinterventions on patients having complicated left main stenoses isdescribed in Mishra, et al., (2006) Am J Cardiol 98:608-612. U.S. PatentPublication US 2008/0147160 describes a catheter having an expandablecage structure located in the Sinus of Valsalva for stabilizing a guidewire in transapical valve replacement procedures. The use of a“parachute” valve for providing a temporary aortic valve is described inVandenberghe, et al., (2008) ASAIO J 54:547-577.

BRIEF SUMMARY OF THE INVENTION

The present invention provides methods and systems for regulating aorticregurgitation during aortic valve replacement and/or repair procedures.As used herein, “aortic regurgitation” refers to the retrograde flow ofblood back from the aorta toward the aortic valve during ventriculardiastole. In replacement/repair procedures where the native aortic valveleaflets are prevented from closing or excised, retrograde flow throughthe valve annulus can interfere with the procedure and potentially harmthe patient.

The present invention provides a variable occlusion device which ispositioned in the ascending aorta just above the Sinus of Valsalva tocontrol regurgitation during diastole while allowing less impededantegrade blood flow to the aorta from the left ventricle duringsystole. In addition, as described in more detail below, the presentinvention will permit a controlled level of retrograde flow(regurgitation) from the aorta during diastole in order to perfuse thecoronary arteries which is necessary to maintain the health of the heartduring beating heart procedures.

While controlled retrograde flow during ventricular diastole can beprovided by fixed, partial occlusion devices positioned in the ascendingaorta above the Sinus of Valsalva, as described in commonly ownedapplications US 2009/0030503 and US 2009/0030510, the present inventionprovides for variable occlusion of blood flow through the aorta so thatthe degree or level of occlusion can be selected and changed duringdifferent portions of the cardiac cycle (systole and diastole) as wellas during different portions of the procedure, e.g., valve ablation,valve excision, prosthetic valve implantation, etc. Thus, for example,during ventricular diastole, the percentage of aortic luminal occlusioncan be maximized to limit regurgitation through the aortic valve annuluswhile providing a sufficient level of coronary artery perfusion throughthe Sinus of Valsalva. During ventricular systole, in contrast, thepercentage of occlusion of the aortic lumen will be lessenedconsiderably. While some small level of occlusion will be present due tothe cross-sectional area of the catheter and/or other tool which isholding the occlusion device, it is theoretically possible to reduce theadditional occlusion provided by the variable occlusion device to alevel close to zero. While such minimal occlusion is desirable tomaximize antegrade flow through the aorta, it will usually be desirableto maintain balloons or other expandable elements in order to stabilizethe catheter or other tool access (resulting in a finite but acceptablelevel of resistance to antegrade flow).

Methods according to the present invention for regulating aorticregurgitation during aortic valve replacement or repair procedurescomprise positioning a catheter or other tool having a variableocclusion device in the ascending aorta above the Sinus of Valsalva. Theocclusion device is expanded to partially occlude the aortic lumenduring ventricular diastole to inhibit aortic regurgitation whileallowing perfusion of the coronary arteries via the Sinus of Valsalva.During ventricular systole, however, the occlusion device is partiallyor fully contracted in order to reduce occlusion of the aortic lumen andlessen inhibition of antegrade blood flow from the left ventricle to theaorta. Expansion and contraction of the occlusion device is typicallycontinued in synchrony with the cardiac cycle (diastole followed bysystole) while the repair or replacement procedure is performed.

The extent of expansion of the occlusion device during ventriculardiastole is selected to optimize perfusion of the coronary arteries viathe Sinus of Valsalva while limiting regurgitation toward or through theaortic annulus. It will be appreciated that whether aortic regurgitationactually occurs will also depend on what is happening in the aorticannulus during the repair or replacement procedure. For example, if aballoon or other structure is expanded within the aortic annulus, thatballoon or other structure may completely prevent retrograde flowthrough the annulus. Perfusion of the coronary arteries via the Sinus ofValsalva, however, should continue regardless of what steps are beingperformed in the repair or replacement procedure.

The degree of occlusion of the aorta during ventricular diastole willpreferably be at least 40%, usually in the range of 40% to 90% and moreusually from 50% to 90% of the cross-sectional area of the aortic lumenwhere the occlusion device is present. In contrast, the percentageocclusion provided by the occlusion device (including thecross-sectional area of the catheter or other device which carries theocclusion device) during ventricular systole will be less than theocclusion provided during ventricular diastole. Usually, the occlusionof the aortic lumen during ventricular systole will be no greater than75%, usually being no greater than 65%, and often being no greater than25%. While there is no upper limit on the patency of the aortic lumenduring ventricular systole (ideally there would be no occlusion), therewill usually be some occlusion resulting from both the cross-sectionalarea of the catheter or other supporting device and, particularly in thecase of inflatable balloons, the presence of two, three, or moreballoons which are inflated about the catheter in order to stabilize thecatheter during ventricular systole where the ejected blood candestabilize the catheter or other tool.

The occlusion device could have any one of many structuralmanifestations. For example, the occlusion could have an expandablescaffold with a plurality of one-way valve structures where individualones of the valve structures could be separately controlled to allowopening and closing at desired portions of the cardiac cycle. Moreusually, however, the occlusion device will comprise at least oneinflatable element or structure, typically comprising multiple,separately inflatable structures, e.g., “balloons.” Such inflatableballoons are generally preferred as they are widely used incardiovascular devices and procedures and allow for highly reliableperformance with minimum risk to the patient. Moreover, the balloonsthemselves can be made in a variety of ways in order to provide fordifferent structural mechanical attributes. For example, the balloonsmay be distensible (usually elastomeric) or non-distensible, may havecircular cross-sections or non-circular cross-sections, can beseparately inflated or inflated through common manifolds in order toinflate and deflate groups of balloons simultaneously, and the like.While certain specific balloon constructions will be described andillustrated in detail below, it should be appreciated that other balloonand mechanical structures would be suitable (although perhaps lesspreferable) for performing the methods and providing the systems of thepresent invention.

Catheter positioning will usually be achieved intravascularly over theaortic arch. Introduction of a catheter over the aortic arch, in turn,can be accomplished using conventional techniques, e.g., introduction ofa catheter by the Seldinger technique or via a surgical cut down intothe femoral artery in the groin. Alternatively, the catheter used toposition the variable occlusion device of the present invention could beintroduced percutaneously through the apex of the heart, referred to asa “transapical” approach. In such cases, the catheter would pass throughthe aortic valve before reaching the ascending aortic through the Sinusof Valsalva. Generally, however, intravascular approaches are preferredover transapical approaches. In addition, catheters used forintravascularly positioning the occlusion device over the aortic archcan also be used for introducing catheters and other tools for repairingor replacing the aortic valve, as described in more detail below. Inparticular, the transaortic catheters can be used for advancing thereplacement valve through a lumen in the catheter, typically while thecatheter remains stabilized by continued balloon expansion in theascending aorta. In addition, the transaortic catheters can be used forintroducing tools for ablating, removing, or otherwise preparing thenative aortic valve for the repair or replacement procedure, as well asfor introducing tools for manipulating and expanding the replacementaortic valve.

Systems according to the present invention comprise a catheter having anexpandable and contractible occlusion device near its distal end. Thecatheter is adapted to be introduced into the aorta, and the occlusiondevice is sized to partially occlude the ascending aorta above the

Sinus of Valsalva when fully expanded. An inflation controller isconnectable to the catheter to alternatively (1) expand the occlusiondevice during ventricular diastole to inhibit aortic regurgitation whileallowing perfusion of the coronary arteries via the Sinus of Valsalvaand (2) to contract or reduce the size of the occlusion device duringventricular systole to lessen inhibition of antegrade blood flow fromthe left ventricle to the aorta. The systems will typically furtherinclude a sensor to detect ventricular diastole and ventricular systole.For example, a heart rhythm monitor (EKG) may be provided to detectventricular diastole and systole. Alternatively, a pressure sensor maybe provided in the system, typically on or near a distal end of thecatheter, to detect ventricular diastole and systole based on pressurein the ascending aorta or elsewhere in the vasculature.

The occlusion device on the catheter will be sized, when fully expandedduring diastole, to occlude to at least 40% of the aortic lumen areawhere positioned, usually occluding from 40% to 90%, and often from 50%to 90%. The degree or amount of occlusion when the occlusion device isfully or partially deflated during systole will be much less, neverbeing above 75% of the aortic lumen area, usually being less than 65%and preferably being below 25% of the lumen area.

The occlusion device may have any of the various structures describedabove with respect to the method of the present invention. Inparticular, it may comprise one or more inflatable elements, typicallycomprising a plurality of independently inflatable elements, where theinflation controller inflates and deflates certain ones of the pluralityof elements simultaneously. Alternatively, the inflation controller mayinflate and deflate individual ones of the plurality of inflatableelements independently. Usually, the inflation controller will maintaininflation of one or more elements at all times during the procedure inorder to stabilize the position of the catheter in the ascending aorta.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic illustration of a native aortic valve and thesurrounding tissue structures including the ascending aortic, the Sinusof Valsalva, and the coronary ostium leading to the coronary arteries.

FIG. 2 illustrates a system constructed in accordance with theprinciples of the present invention including a temporary aortic valve(TAV) catheter and system controller.

FIG. 2A illustrates a multiple-balloon structure present at a distal endof the catheter of the system in FIG. 2 with all balloons inflated.

FIG. 2B is similar to FIG. 2A showing the configuration when every otherballoon is deflated.

FIG. 3A illustrates the catheter of the system of FIG. 2 positioned inan ascending aorta during systole.

FIG. 3B is a cross-sectional view taken along line 3B-3B of FIG. 3A.

FIG. 4A illustrates the catheter of the system of FIG. 2 positioned inan ascending aorta during diastole.

FIG. 4B is a cross-sectional view taken along line 4B-4B of FIG. 4A.

FIGS. 5A and 5B illustrate an alternative balloon configuration with theballoons fully inflated in FIG. 5A and partially inflated in FIG. 5B.

FIGS. 6A and 6B illustrate an alternative balloon configuration with theballoons fully inflated in FIG. 6A and partially inflated in FIG. 6B.

FIGS. 7A-7F illustrate use of the catheter of the system of FIG. 1 forablating and replacing a native aortic valve with a percutaneous aorticvalve (PAV) in accordance with the present invention.

FIG. 8 illustrates certain balloon configurations which are analyzed inthe Calculations section herein below.

DETAILED DESCRIPTION OF THE INVENTION

A native aortic valve (NAV) is illustrated in FIG. 1. The native aorticvalve is positioned just below the ascending aorta (AA) and the Sinus ofValsalva (SV). Coronary ostia (CO) branch off from the Sinus of Valsalvaand provide perfusion to coronary arteries which feed the heart muscle(not illustrated). Beneath the native aortic valve is the leftventricle, and the aortic valve is closed during diastole (as shown infull line in FIG. 1) and opens during systole (shown in broken line inFIG. 1) when the left ventricle contracts and ejects blood from theventricle into the aorta.

Referring to FIG. 2, a system 10 for regulating aortic regurgitationaccording to the present invention comprises a temporary aortic valve(TAV), catheter 12 and a controller 14. The catheter 12 has a balloonstructure 16 at or near its distal end and an inflation hub 18 at ornear its proximal end. In the illustrated embodiment, the balloonstructure 16 includes six identical cylindrical balloons disposedcoaxially and symmetrically about the body of the catheter 12. FIG. 2Aillustrates individual balloons 20 of the balloon structure 16, with allthe individual balloons being inflated. FIG. 2B is similar to FIG. 2A,except that only three of the balloons 20 a are inflated while threeother balloons 20 b (only one of which can be seen in FIG. 2B) aredeflated.

The system controller 14 will provide for balloon inflation, typicallyproviding at least one inflation tube or conduit 22 which is connectedto the hub 18. Optionally, individual branches of the inflation conduit22 can be manifolded into a plurality of inflation connectors 24 on theinflation hub 18. It will be appreciated that internal valving withinthe controller 14 and/or the hub 18 may allow for selective inflation ofindividual ones and/or individual groups of the balloons 20 of theballoon structure 16.

The controller 14 will typically also receive input from a sensor whichprovides information regarding the cardiac cycle, usually providinginformation on the transition between ventricular systole and diastoleso that the individual ones of the balloons may be inflated and deflateddepending on the status of the cardiac cycle, as described in moredetail below. The sensor (not illustrated) may be an EKG attachedexternally to the patient or may be a pressure sensor located on thecatheter 12 itself. The controller 14 may be set to inflate and deflatethe selected balloons during every cardiac cycle (a 1:1 duty cycle) orevery other cardiac cycle (a 1:2 duty cycle) or every third cardiaccycle (a 1:3 duty cycle) or every “nth” cardiac cycle (a 1:n duty cycle,n typically being from 1 to 10) for the best hemodynamic response basedon cardiac output, blood pressure, pulse rate, and the like.

The TAV catheter will usually have dimensions and physical propertiescompatible with introducing the catheter over the aortic arch so thatthe balloon structure 16 may reside within the ascending aorta justabove the Sinus of Valsalva. Usually, the catheter 12 will have atubular body with a large central lumen 26 which may be utilized toprovide access to the aortic valve during replacement and repairprocedures. The catheter 12 will also usually include individual orcommon lumens providing for inflation of the individual balloons 20.These lumens may be provided, for example, within the wall of the bodyof catheter 12 and formed during extrusion (not illustrated). Otherconventional means for providing balloon inflation lumens may also beutilized.

Referring now to FIGS. 3A and 3B, the catheter 12 may be positioned overthe aortic arch so that the balloon structure 16 lies in the ascendingaorta. By inflating selected balloons 20 a while leaving the otherballoons deflated during systole, blood may be ejected from the leftventricle (LV) through the open native aortic valve (NAV) during systoleso that blood flows past the balloon structure 16 with the deflatedballoons decreasing flow resistance.

Referring now to FIGS. 4A and 4B, the balloon structure 16 will have allballoons 20 a inflated during diastole in order to limit retrograde flowwhile still permitting perfusion of the coronary arteries through thecoronary ostia. While the native aortic valve (NAV) shown in FIGS. 3Aand 3B and in FIGS. 4A and 4B is quite healthy, it will be appreciatedthat the TAV catheters of the present invention will be used duringreplacement procedures where the valve is unhealthy to begin with(likely subject to significant stenosis and/or regurgitation) and thatthe purpose of the variable occlusion is to control regurgitation whilethe valve is being treated and, at many points during the procedure,where the valve annulus is fully or partially open without any activevalve mechanism.

While the balloons 20 of the balloon structure 16 of TAV catheter 12 areshown as cylindrical with symmetric placement about the catheter, itwill be appreciated that a wide variety of other balloon numbers,configurations, and inflation patterns may be utilized. For example, asshown in FIG. 5A, it may be possible to employ four pie-shaped balloons,with two larger balloons 30 and two smaller balloons 32. When theballoons are fully inflated, as shown in FIG. 5A the smaller balloonsleave flow channels 34 a bypassing the balloon structure. The size ofthe flow passages 34 a will be selected to be compatible with thedesired retrograde flow of regurgitation during diastole. In contrast,the smaller balloons 32 may be deflated, as shown in FIG. 5B to providemuch larger flow passages 34 b, to be utilized during systole.

Similarly, as shown in FIGS. 6A and 6B, cylindrical balloons may havedifferent geometries and different sizes. Two larger cylindricalballoons 40 are disposed on opposed sides of the catheter 12 while twosmaller cylindrical balloons 42 are disposed between the larger balloons40 and on opposed sides of the catheter 12. The smaller balloons 42 maybe inflated (as shown in FIG. 6A) during diastole and deflated (as shownin FIG. 6B) during systole (as shown in FIG. 6B). Usually, the largerballoons 40 will remain inflated at all times in order to stabilize thecatheter 12 during the replacement or repair protocol.

Referring now to FIGS. 7A through 7F, an exemplary aortic valvereplacement procedure which utilizes the TAV catheter 12 of the presentinvention will be described. As shown in FIG. 7A, the TAV catheter 12 isplaced in the ascending aorta (AA) over the aortic arch (not shown) viaan intravascular procedure. After predilation with a balloon, anablation stent 50 is placed within the native aortic valve by inflatinga balloon 52 carried by a catheter 54 introduced through the lumen 26 ofthe catheter 12. The stent 50 is used to open and/or ablate the nativevalve in a generally conventional manner. During the ablation procedure,the balloons 20 will be selectively expanded and contracted as describedpreviously. As shown in FIG. 7A, the balloons 20 are fully inflated tominimize retrograde flow while allowing adequate perfusion of thecoronary arteries through the coronary ostia (CO), as shown by thearrows in FIG. 7A. It will be appreciated that the balloons will inflateand deflate during the procedure regardless of the inflation ordeflation of balloon 52 or other balloons as utilized later in theprocedure.

Referring now to FIG. 7B, the catheter 54 carrying balloon 52 has beenremoved with the stent 50 being left in place. At this point in theprocedure, the stent 50 is fully opened and, were it not for the balloonstructure 16 on catheter 12, the aortic annulus and left ventricle wouldbe exposed to uncontrolled regurgitation of blood from the aorta duringdiastole. As shown in FIG. 7B, however, the selected balloons 20 b aredeflated during systole so that blood may flow from the left ventricle,through the stent 50 in the direction of the arrows past the deflatedballoons. It will be appreciated, however, that during the next cycle ofdiastole, the balloons 20 b will reinflate, as shown in FIG. 7A, tolimit the retrograde flow and aortic regurgitation while permittingsufficient retrograde flow to perfuse the coronary arteries via thecoronary ostia (CO).

Referring now to FIG. 7C, the next stage of the valve replacementprotocol is introducing the percutaneous aortic valve (PAV) 60 using asecond catheter 64 having a balloon 62. As shown in FIG. 7C, the heartis in ventricular diastole, and the blood is flowing past the fullyinflated balloons 20 and perfusing the coronary arteries through thecoronary ostia (CO). As soon as the heart enters systole, the balloons20 b will deflate, as shown for example in FIG. 7B.

Referring now to FIG. 7D, the balloon 62 is inflated to deploy the PAV60 within the previously placed stent 50. As illustrated in FIG. 7D, theheart is in systole but the inflation of balloon 62 prevents blood fromflowing from the left ventricle through the aortic annulus. Thus, bloodwill remain temporarily still within the Sinus of Valsalva since theheart, during systole, inhibits flow of blood into the coronaryarteries.

Referring now to FIG. 7E, after the PAV 60 has been deployed, thecatheter 64 carrying balloon 62 will be removed leaving the TAV catheter12 temporarily in place. As the heart is in diastole, the retrogradeflow past fully inflated balloons 20 will occur and will perfuse thecoronary arteries via the coronary ostia (CO). The PAV leaflets,however, will be closed preventing valve regurgitation.

Finally, as shown in FIGS. 7F, the TAV catheter 12 is removed leavingthe PAV 60 to function in a normal manner. In FIG. 7F, the heart isshown in systole with blood flow through the open leaflets of the valve.As soon as the heart enters ventricular diastole, however, the valveleaflets of valve 60 will close and prevent regurgitation.

Calculations

To quantify the gap-to-balloon relationships which produce effectivemild-to-moderate range aortic stenosis and insufficiency of thetemporary aortic valve, mathematical calculations are performed on TAVmodels comprising three to six balloons of the same sizes surrounding acentral catheter (FIG. 8). The choice of using the same size balloons isto ease calculation and manufacturing complexities, though it is not arequirement as long as the resultant cross-section are of thegap:overall luminal aorta ratios are between the target range of 25 to60%. Hence, balloons of various sizes and configurations (non-circular)may be design options in future developments.

The potential benefits of balloon counterpulsation to further unload thetemporary valve's effective stenosis, various balloon counterpulsationpermutations are explored as shown (FIG. 8). Balloon counterpulsation isdefined as balloon inflation during diastole and balloon deflationduring systole similar to the timing cycle of the intra-aortic balloonpump. (Safian and Feed, Intra-aortic Balloon Counterpulsation, Manual ofInterventional Cardiology 3^(rd) Ed., royal Oak, Mich., Physicians'Press, pp 146-147). During TAV balloon counterpulsation, certainconfigurations may be potentially mechanically less stable such as whenall of the balloons counterpulsate and may lead to some catheterinstability (fling or wobble). Unstable configurations, such as singleor double balloon counterpulsation in the three-balloon TAV, threeballoon counterpulsation in the four-balloon TAV, three-ballooncounterpulsation in the five-balloon TAV and four-ballooncounterpulsation in the six-balloon TAV, are not considered in thecalculations.

TAV permutations considered in the calculations are the following:counterpulsation of all of the TAV balloons (the middle row of FIG. 8),countepulsation of the cater-corner balloons in the four-balloon TAV(the remaining two as fixed supportive balloons), counterpuslation ofthe two opposing balloons in the five-balloon TAV (three remaining fixedsupporting balloons) and counterpulsation of every other balloon in thesix-balloon TAV (others as fixed support balloons) (the bottom row ofFIG. 8).

Results

Table 1 (top row) shows the relationship between the radius of the aorta(R) to the radius of the TAV balloons (r) and the radius of the centralcatheter (h) for the 3-, 4-, 5- and 6-balloon TAV configurations. Asfirst reported in the original TAV study, the 3-balloon TAVcross-sectional gap area:total area of the ascending aorta is calculatedto be approximately 35%, which falls in the moderate range effectiveaortic stenosis and insufficiency during systole and diastole,respectively. As the number of balloons surrounding the central catheterincreases, the balloon size becomes smaller as demonstrated by theincreasing R:r ratio. Furthermore, as the balloon size becomes smaller,the center space becomes larger allowing for a larger lumen centralcatheter to be housed as shown by the decreasing R:h ratio. In the4-balloon configuration, the diastolic gap area:total area ratio islowered to 28% compared to the 3-balloon TAV's 35%, which decreases theeffective aortic insufficiency. As the number of balloons increases to 5and 6, the respective diastolic gap area:total area ratio is furtherlowered to 25% and 22%. While the effective TAV aortic insufficiencydecreases with increasing number of balloons, the effective aorticstenosis can increase to beyond critical range (gap:total area <25%) inthe 5- and 6-balloon TAV. This would entail less effective aorticinsufficiency by the TAV which may or may not be adequate for coronaryperfusion during diastole, however, during systole the TAV's effectiveaortic stenosis will become significant.

TABLE 1 Comparative TAV Configurations with Fixed (Inflated withoutCounterpulsation) Balloons Dimensional Relationship 3-Balloon TAV4-Balloon TAV 5-Balloon TAV 6-Balloon TAV R:r ratio R = 2.15 r R = 2.41r R = 2.70 r R = 3.0 r R:h ratio R = 14.29 h R = 5.88 h R = 3.85 h R =3.0 h Gap:Area 35% 28% 25% 22% TAV's Effective AS Moderate ↑ ↑↑ ↑↑↑TAV's Effective AI Moderate ↓ ↓↓ ↓↓↓ Estimated Central Catheter 7-FR.17-FR. 26-FR. 32-FR. Size

The central catheter diameter is dependent on the size of the ascendingaorta (as indicated by the R:h ratio) as well as the number of TAVballoons (Table 1). For average size adult human ascending aorta, thecentral catheter-TAV can conceptually be fabricated to be as small as a7-French system to as excessively large as 30-French or greater. Tables2A and 2B show the effects of balloon counterpulsation when all (Table2A) or some (Table 2B) of the TAV balloons are inflated-deflated timedto the cardiac cycle as described. When the TAV balloons are deflatedduring systole and inflated during diastole via ballooncounterpulsation, it can alleviate or lower the degree of effectiveaortic stenosis while keeping the controlled effective aorticinsufficiency unchanged. When all of the balloons of the TAVcounterpulsate, the effective aortic stenosis is significantly reducedto negligible to very mild ranges as shown in Table 2A. In the 4-balloonconfigured TAV, counterpulsation of two selective cater-corner balloonswhile keeping the other two as fixed support decreases the effectiveaortic stenosis during systole to a gap area:total area ratio of 62.7%,as compared to 28% without counterpulsation. Similar improvement in thesystole effective aortic stenosis is seen in the five- and six-balloonTAV with selective balloon counterpulsation as noted in Table 2B, withthe systole gap area:total area of 52.1% and 55.6%, respectively. Notethat balloon counterpulsation is most relevant in the five- andsix-balloon configurations where the effective aortic stenosis is atcritical values. Hence, balloon counterpulsation appears to present aunique advantage over the fixed-balloon TAV system.

TABLE 2A Counterpulsation with All of the Balloons DimensionalRelationship 3-Balloon TAV 4-Balloon TAV 5-Balloon TAV 6-Balloon TAVGap:Area (systole) 99% 97% 93% 88% Gap:Area (diastole) 35% 28% 25% 22%TAV's Effective AS Negligible Negligible Very Mild Very Mild (systole)TAV's Effective AI Moderate Moderate Mild-Moderate Mild (same (diastole)(same as fixed) (same as fixed) as fixed)

TABLE 2B Counterpulsation with Selected Balloons DimensionalRelationship 3-Balloon TAV 4-Balloon TAV 5-Balloon TAV 6-Balloon TAVGap:Area (systole) — 62.7% 52.1% 55.6% Gap:Area (diastole) 35%   28%  25%   22% TAV's Effective AS Moderate Mild Mild Mild (systole) TAV'sEffective AI Moderate Moderate Mild-Moderate Mild (same (diastole) (sameas fixed) (same as fixed) as fixed)

These calculations demonstrate the design potential to manipulate andcontrol the TAV's effective aortic stenosis and insufficiency by varyingthe number of balloons used to create the TAV and by adding ballooncounterpulsation to lessen the systolic effective TAV stenosis. From thedesign standpoint, there are a variety of ways to create the optimalgap:total cross-sectional area ratio for the desirable effective TAVstenosis and insufficiency via non-circular vs. circular balloons,non-uniform vs. uniform balloons and non-balloon structures. The initialchoice of using balloons of the same size in each TAV is to simplifymathematical modeling and manufacturing process. The choice of usinginflatable balloons in the TAV is for its ease of deployment andremoval.

As the number of balloons increases in a given size ascending aorta, thesize of the balloons will decrease as clearly demonstrated by the R to rratio. The relationship between R and h will also influence the size ofcatheter used. Furthermore, the distance between the balloons and thecenter of the ascending aorta will also increase as the number ofballoons increases. Hence, with more balloons in the TAV, there will bea larger space in the center of the ascending aorta to house a largercentral catheter. In the fixed balloon TAV permutations, the effectiveaortic stenosis increases as the number of balloons increases, while theeffective aortic insufficiency decreases accordingly. The TAV modelpermutations may allow for opportunity for catheter size fitting ortailoring based on the aortic size, the number of balloons on the TAVand the associated hemodynamic profile.

In the five- and six-balloon TAVs, the systolic effective aorticstenosis reaches critical range of 25%, which is unacceptable in thereplacement of severe aortic stenosis procedure. In these cases, ballooncounterpulsation appears mandatory to alleviate the excessive TAVstenosis during systole. Also in the five- and six-balloon TAVconfigurations, the effective aortic insufficiency during diastolelowers toward mild range which is fabulous in preventing excessiveregurgitation and congestive heart failure but could limit adequatecoronary perfusion. The follow-on animal studies will be able todetermine the relationship between the degree of TAV's effectiveinsufficiency and diastole coronary filling.

With the addition of balloon counterpulsation, it is found that theTAV's effective aortic stenosis during systole can be significantlyreduced, while the effective aortic insufficiency during diastole isunchanged. For all of the balloon configurations used in thecalculations (three-, four-, five- and six-balloon TAVs), the systoliceffective aortic stenosis is reduced to negligible ranges (when allballoons counterpulsate) to mild ranges (when selective balloonscounterpulsate). This reduction in antegrade blood flow obstruction canfurther help to stabilize the patient during the percutaneous aorticvalve replacement procedure. This is particularly true for the five- andsix-balloon TAVs where the effective aortic stenosis is already in thecritical range in the fixed balloon models. The tremendous relief ofeffective TAV stenosis by counterpulsating all of the balloons isimpressive, but is at the least partially offset by the increasedpotential for catheter instability (fling or wobble) which must beconsidered and mitigated in the final design. Counterpulsating selectivealternating balloons can unload the effective TAV stenosis, while thestationary balloons can continue to serve as catheter support/anchorduring the entire valve replacement procedure.

These calculations represent conceptual permutations of the original TAVdesign provided in U.S. 2009/0030503 and U.S. 2009/0030510 as anevaluation to optimize its function as mechanical and hemodynamicsupport for the percutaneous aortic valve replacement procedure. Thepresented mathematical calculations are limited to idealized modelswhere the balloons stay circular, the ascending aorta has a circularcircumference free of atherosclerotic irregularities, perfect contactsbetween balloons and the aortic wall without slippage, leakage orresonance vibrations. In reality, the balloon compliance may encroachupon the gaps, creating more than expected contacts with the aorticwall, and the gap:total cross-sectional area ratio may further bealtered by the irregular aortic profile from disease conditions.Excessive and/or inadequate TAV-aortic wall contacts can occur. Animalvalidations along with the theoretical model analyses are vital indeveloping TAV system into a successful supportive device in PAVR.

In conclusion, the ability to adjust and improve the TAV's function ispossible by varying the number and/or geometry of the balloons utilizedand implementing balloon counterpulsation. Optimized of deviceconfigurations will also depend on other factors such as the desirableguide catheter size and the required TAV hemodynamic profiles. The TAVballoon counterpulsation should not be confused with IABPcounterpulsation in that the balloon volume of the TAV is significantlyless (30-40 cc in IABP vs. <3 cc in TAV) without full aortic occlusionand should be safe to use with the presence of aortic insufficiency.Similar to the hemodynamic support of IABP in high-risk percutaneouscoronary interventions, however, the TAV can provide additionalhemodynamic support to optimize patient safety and procedural outcome inPAVR.

While the above is a complete description of the preferred embodimentsof the invention, various alternatives, modifications, and equivalentsmay be used. Therefore, the above description should not be taken aslimiting the scope of the invention which is defined by the appendedclaims.

What is claimed is:
 1. A device for regulating aortic regurgitation,said device comprising: a tubular catheter body advancable through anascending aorta of a subject; a first occlusion element disposed at adistal end of the catheter body; and a second occlusion element disposedat the distal end of the catheter body in parallel with the firstocclusion element, wherein the first and second occlusion elements aresized to at least partially occlude the ascending aorta when positionedtherein, wherein the first and second occlusion elements areindependently expandable and contractable, and wherein the firstocclusion element is configured to expand and contract in synchrony withdiastole and systole of a cardiac cycle, respectively, while the secondocclusion element is configured remain expanded through the cardiaccycle.
 2. The device of claim 1, wherein the tubular catheter body has acentral lumen through which a replacement valve or other interventionaltool can be advanced through.
 3. The device of claim 1, wherein thefirst and second occlusion elements are disposed symmetrically about thedistal end of the catheter body.
 4. The device of claim 1, wherein thefirst occlusion element comprises a first inflatable element and thesecond occlusion element comprises a second inflatable element.
 5. Thedevice of claim 4, wherein the first inflatable element comprises afirst inflatable balloon and the second inflatable element comprises asecond inflatable balloon.
 6. The device of claim 4, wherein the firstand second inflatable elements are coupled to an inflation controllerthrough at least one inflation tube.
 7. The device of claim 6, whereinthe inflation controller comprises a plurality of inflation connectorssuch that internal valving within the inflation controller allows forselective inflation of the first and second inflatable elements.
 8. Thedevice of claim 6, wherein the inflation controller is coupled to acardiac cycle sensor and the inflation controller selectively inflatesand deflates the first and second inflation elements in response to thecardiac cycle sensor.
 9. The device of claim 8, wherein the cardiaccycle sensor comprises a heart rhythm monitor.
 10. The device of claim8, wherein the cardiac cycle sensor comprises a pressure sensor.
 11. Thedevice of claim 10, wherein the pressure sensor is disposed near adistal end of the tubular catheter body.
 12. The device of claim 1,wherein the first occlusion element comprises a first plurality ofexpandable elements and the second occlusion element comprises a secondplurality of expandable elements.
 13. The device of claim 12, whereinthe expandable elements of the first plurality of expandable elementsalternate with the expandable elements of the second plurality ofexpandable elements about the distal end of the catheter body.
 14. Thedevice of claim 1, wherein the first and second occlusion elementsocclude no more than 65% of the ascending aorta when both contracted.15. The device of claim 1, wherein the first and second occlusionelements occlude no more than 50% of the ascending aorta when bothcontracted.
 16. The device of claim 1, wherein the first and secondocclusion elements occlude no more than 25% of the ascending aorta whenboth contracted.
 17. The device of claim 1, wherein the first and secondocclusion elements occlude from 40% of 90% of the ascending aorta whenboth fully expanded.
 18. The device of claim 1, wherein, when the firstand second occlusion elements are positioned in the ascending aorta, thefirst and second occlusion elements are both expanded during diastole toinhibit aortic regurgitation while allowing perfusion of the coronaryarteries via the sinus of valsalva.
 19. The device of claim 1, wherein,when the first and second occlusion are positioned in the ascendingaorta, the first occlusion element is contracted while the secondocclusion element is expanded during systole to lessen inhibition ofblood flow from the left ventricle to the aorta.
 20. The device of claim1, wherein the first occlusion element is configured to expand andcontract with diastole and systole, respectively every 1 of n cardiaccycles, where n is an integer from 1 to 10.